Friday, January 23, 2015

Long Case with Dr. Hasnur

Patient 1

Mr. M, 80 years old, an ex-smoker with underlying hypertension, hyperlipidemia, gastritis and ischaemic heart disease, presented with sudden onset of left-sided chest pain for one day duration. The pain was burning in nature, radiate to left axilla, shoulder and back, duration was more than 10 minutes, not relieved by GTN, pain score 10/10. It was associated with shortness of breath and palpitation. There was no history of orthopnea or PND.

He was diagnosed as myocardial infarct in 2000, was unsure of any intervention done on him. There was previous history of similar episodes in the past, but always relieved by GTN. He is on T. Isosorbide Dinitrate, T. GTN, T. Lovastatin, T. Perindopril, T. Cardipin, T. Amlodipine. He is a known case of sinus bradycardia.

Physical examination showed no stigmata of infective endocarditis, no raised JVP. Patient afebrile, HR 43 regular rhythm and volume, BP 100/60, RR 18. Cardiovascular examination normal. S1 S2 heard with no murmur.

1. Provisional diagnosis?
Acute myocardial infarct

2. Differentials?
  • Acute coronary syndrome (STEMI, NSTEMI, unstable angina)
  • Pulmonary Embolism
  • Aortic dissection
  • Pericarditis

3. Investigations?
FBC, PT/APTT, cardiac biomarkers, ECG, CXR, ECHO

4. Management? MONAsH
  • Morphine
  • Oxygen
  • Nitroglycerin eg. GTN
  • Aspirin
  • Heparin
Long term : control risk factors, stop smoking, cardiac rehab, lifestyle modification, continue aspirin, patient education etc.

Patient 2

Puan K, a 50-year-old female with underlying Type 2 Diabetes Mellitus and hypertension, presented with one week history of worsening shortness of breath associated with progressive lower limb and body swelling. It was associated with orthopnea, PND and reduced effort tolerance. She was just discharged from HTAA three weeks ago, and swelling had reduced after discharge. She was put on ROF 600 ml/day.

Physical examination revealed a medium build lady who looked pale. BP 180/60. She had distended abdomen and bilateral pedal edema. Fluid thrill positive, sacral edema present. Respiratory examination revealed fine crepitations heard bilaterally.

1. Differentials?
Fluid overload secondary to:
  • Heart - IHD or hypertensive cardiomyopathy
  • Renal - CKD or nephrotic syndrome
  • Liver - CLD or liver congestion

2. Investigations?
FBC, RP, LFT, CXR, Funduscopy, screen for risk factors etc.

3. Management?
ACE-i, manage risk factors, patient education etc.

Tips : Read on Multiple Sclerosis, Parkinson's, stroke, spastic paraperesis and spinocerebellar ataxia for Pro Exam clinical cases.

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